1.3. RESULTS
A total of 1388 patients were scheduled to undergo cardiac surgery
during the study period, 981 (70.7%) elective and 407 (29.3%) urgent.
Table 1 shows patients’ characteristics. Myocardial Infarction (MI)
status was the only significant difference between C and NC groups.
Cancelled patients were more likely to have had a previous MI, with
40.2% (82/204) in C and 30.1% (338/1123) in NC affected (p=0.004).
Operative procedures included isolated coronary artery bypass grafting
(CAGB) in 47.9% (665/1388), isolated valve replacement and/or repair in
27.8% (386/1388), combined valve and CABG in 13.2% (183/1388), and
other in 11.1% (154/1388). Overall, 16.6% (231/1388) of operations
were cancelled on the day of surgery. The number of cancellations in the
urgent group (21.6%, 88/231) was significantly higher than in the
elective group (14.6%, 143/231) (p=0.001).
There was no difference in in-hospital mortality between the C and NC
groups, with 2.6% (6/231) deaths in C group and 1.6% (19/1157) in NC
group (p=0.62). Similarly, there was no difference in mortality between
the C and NC patients within the urgent group (C urgent 4.5% (4/88) vs
NC urgent 3.3% (14/343), p = 0.85), and no difference in mortality
within the elective patient group (C elective 1.4% (2/143) vs NC
elective 0.6% (5/814) (p=0.85).
Figure 2 shows the reasons for cancellation of surgery. The most common
reasons for cancellations included: no ITU beds in 30.7% (71/231),
patient medically unfit in 21.6% (50/231), scheduling error in 9.5%
(22/231), no ITU nurses in 8.2% (19/231), patient related issues in
7.8% (18/231), emergency intervening in 6.9% (16/231). Patients were
declared as medically unfit for the following reasons: evidence of
infection (54%, 27/50); further investigations necessary (16%, 8/50),
diarrhoea (6%, 3/50); deranged blood results (6%, 3/50), new
angiography/TOE findings (6%, 3/50), gastric bleed (4%, 2/50), rash
(4%, 2/50); haematuria (2%, 1/50), allergic reaction to pre-operative
antibiotics (2%, 1/50).
‘Scheduling errors’ included overrunning first case in 61.9% (14/22),
operating room overbooking in 22.7% (5/22), late start to the operation
in 14.3% (3/22). Patient-related issues included patient not attending
for surgery in 27.8% (5/18), warfarin not stopped in 22.2% (4/18),
treatment refusal in 16.7% (3/18), self-cancellation in 16.7% (3/18),
late Jehovah witness declaration in 5.6% (1/18), incorrectly completed
consent form in 5.6% (1/18), and private treatment preferred in 5.6%
(1/18).
Our analysis revealed that at least 30.7% (71/231) of cancellations
were potentially preventable. The main reasons identified included ITU
staff shortage in 27% (19/231), surgery no longer needed in 10%
(7/231), lack of perfusionist in 10% (7/231), inadequate work up in 7%
(5/231), and patient not turning up for surgery in 7% (5/231).
Additionally, cancellation rates varied from one consultant to the other
(range 5.9% to 31.7%).
Cancellations occurred whilst still on the ward for 96.1% (222/227) of
patients, intraoperatively for 1.3% (3/227; 2 electrical system
failures and one new declaration of Jehovah Witness) and in the
anaesthetic room for 0.9% (2/227; failed intubation and a new TOE
finding). A different surgeon undertook the cancelled procedure in
26.4% (61/231) of cases; of these, 31.2% (19/61) were cancelled twice,
and 78.9% (15/19) were operated on by a third surgeon.
In-hospital transfer patient cancellations were not higher for patients
scheduled for surgery within 24 hours from admission compared to those
scheduled for surgery beyond 24 hours of admission (25% (5/20) vs
15.3% (22/144), p=0.27).
Figure 3 shows cancellation to operation time. The NHS recommends that
patients requiring any surgery are operated on within 28 days of
cancellation. Operations were performed within this time frame in 99.1%
(221/223) of cases. Patients were operated on within 24 hours in 19.9%
(46/223) and 70.7% (163/223) within 7 days of cancellation. Twenty of
the 223 (8.7%) cancelled patients were not operated on after the
cancellation and instead underwent Percutaneous Coronary Intervention,
Transcatheter Aortic Valve Implantation or medical treatment.
Patients’ pathway post-cancellation outcomes are shown in Figure 4.
Ninety-two patients (39.8%; 92/231) left the hospital within 24 hours
to be re-dated and 33.8% (78/231) stayed for more than 7 days. One
patient remained in hospital for 90 days after the cancellation due to a
cardiac arrest. There was no increase in the total post-operative length
of stay between the two groups with 76.2% (866/1137) of NC patients and
76.2% (173/227) of C patients staying in the hospital longer than 7
days (p=0.988).
Our centre aims to hold pre-admission clinics 2-4 weeks prior to
scheduled surgery. This was achieved for 51.5% (431/837) of patients.
Four hundred and six (48.5%; 406/837) patients were seen beyond 28 days
of the scheduled surgery. Data on the timing of pre-op clinic was
missing in 39.7% (551/1388) cases. Patients who were assessed within 28
days of surgery were less likely to have their procedures cancelled,
12.3% (53/431) of patients seen within 28 days were cancelled compared
to 20.9% (85/406) in those seen beyond 28 days (p=0.001).
All cancelled patients were contacted on at least two different days but
only 101/231 (43.7%) completed our survey; 23.8% refused for the
following reasons: poor English language skills, not willing to answer,
hard of hearing, poor memory of the event and 32.5% did not answer the
phone.
The level of information received about the cancellation was reported as
clear and comprehensible by 13.9% (14/101), acceptable by 67.3%
(68/100) and inadequate by 18.8% (19/101). Cancellation was deemed
justified in 92.1% (93/101) and 90.1% (91/101) denied there was a
party to blame. Of the 10 patients who believed that there was a party
to blame for the cancellation, 30% (3/10) blamed inadequate government
funding, 30% (3/10) the hospital administration, 30% (3/10) the
healthcare system, and 10% (1/10) put it down to miscommunication
between hospitals.
At the time of cancellation 22.8% (23/101) reported feeling upset,
17.8% (18/101) anxious, 12.90% (13/101) confused, 10.9% (11/101)
fine, 8.9% (9/101) disappointed, 6.9% (7/101) happy, and 19.8%
(10/101) other. The majority (72/98 (73.5%)) of patients whose surgery
was rescheduled admitted that they would have preferred to have been
operated on by the same surgeon as originally planned. The waiting time
for the rescheduled surgery was too long according to 19.4% (19/98) of
patients. 26.7% (27/101) of patients reported that the cancellation
negatively impacted their sense of wellbeing, 64.4% (65/101) said it
made no change and 8.9% (9/101) said that it made them feel better
because they had more time to prepare.